Discussion

The rate of attrition for EM residents is low, and it is the lowest when compared to the other 10 largest specialties. This is consistent with results from prior work also demonstrating the relatively low rate of EM resident attrition (1.5%) compared to other specialties.[10] Our investigation did not address whether this finding is due to a positive training environment, appropriate career selection, shorter training programs, or the resiliency of EM trainees, although all are possible contributing factors. While the low attrition rate experienced by EM programs is commendable, the premature loss of a resident during training can still be disruptive and damaging to morale for both the resident and the program. Furthermore, observations on the resident characteristics associated with attrition may inform current efforts to promote inclusion and diversity within the specialty.[12,13]

During the study period, we found that female EM residents were significantly more likely to leave residency than their male colleagues. Female EM residents were also less likely to be dismissed from their programs and significantly more likely to report health or family causes as the reason for their attrition during training than male residents. These findings suggest male and female EM residents may experience different demands in and outside of residency training. For example, prior work demonstrated that while depressive symptoms increased during intern year for both men and women, this increase was significantly greater for women, who cited work-family conflicts as a contributing factor.[14] This discrepancy remains consistent among practicing emergency physicians, for whom factors associated with career satisfaction include schedule flexibility and sufficient time with family.[15,16] In addition, a majority of female physicians reported deferring important life decisions (e.g., getting married, having children) in order to pursue their medical careers.[17]

While it was not clear from our data if childcare had any role in the greater likelihood of female EM residents prematurely leaving their programs, with most medical residents being of child-bearing age, it is possible that the challenges of having and raising children during training play a role in this gender discrepancy. Female residents may also be more likely to be caretakers of elderly parents or other ill family members than their male peers.[18] Current American Board of Emergency Medicine policy on resident leave for any reason recommends up to six weeks of sanctioned time away per year without the requirement of extending residency training.[19] However, the ABEM policy also stipulates that "if a residency program already has a policy in effect for leave time that is less than six weeks, the program may operate according to its own policy."

While a full discussion of the history and controversies surrounding paid parental and family leave in the United States is beyond the scope of this paper,[20] its relevance cannot be overstated in light of the increasing numbers of women who are entering medicine[21] and the growing numbers of physicians from younger generational cohorts (e.g., millennials) who may place greater value on work-life balance than physicians from prior generations.[22] Although our study could not discern the specific circumstances behind a resident's choice to leave training due to "health or family reasons," we suspect standardizing parental, family, and medical leave policies and providing affordable access and support for child and elder care may be steps to help address this gender discrepancy in attrition. Residency programs may also take creative steps to accommodate residents who need to take leave (e.g., scheduling more demanding rotations earlier in pregnancy or allowing residents to design reading or research electives that comply with Residency Review Committee-EM requirements) to minimize the time needed away from training.

There were limited racial differences in EM resident attrition. Although Asian, Hispanic/Latino, and Black/African American residents comprised greater proportions of the attrition population than the overall population, in pairwise comparisons between groups, only Hispanic/Latino residents were significantly more likely to leave and be dismissed from training than their White counterparts. It should be noted that the EM resident attrition rate in all racial/ethnic groups remained low, with each group experiencing a rate less than 2%. Nonetheless, the higher attrition rate experienced by a traditionally under-represented minority group in medicine raises questions about the unique challenges faced by physicians-in-training who are part of this under-represented group. Previous reports have noted that ethnic minority trainees perceive barriers to success in academic medicine that are based on their race.[23–25] These barriers may also be present in the training environment of EM programs and could partially account for this difference in attrition.

EM, emergency medicine; CI, confidence interval; df, degrees of freedom.*χ2=67.516; df=24; p<0.001. American Indian/Alaska Native, Native Hawaiian/Pacific Islander, Other, and Unknown were not included due to their small sample sizes.

References

Authors and Disclosures

Authors and Disclosures

*Tufts University School of Medicine, Department of Emergency Medicine, Medford, Massachusetts†Maine Medical Center, Department of Emergency Medicine, Portland, Maine‡Wake Forest School of Medicine, Department of Emergency Medicine, Winston-Salem, North Carolina§The University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado¶The Ohio State University College of Medicine, Department of Emergency Medicine, Columbus, Ohio

Conflicts of Interest By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. This study was supported by funding from the Council of Emergency Medicine Residency Directors awarded in July 2017.